Drug blunder killed new mother

NHS negligence caused the manslaughter of a new mother just minutes after she gave birth, a jury inquest found in a landmark case.

Mayra Cabrera, 30, died after giving birth to son Zac when Bupivacaine, a potent epidural anaesthetic, was mistakenly attached to an intravenous drip feeding into a vein in her hand on May 11 2004.

She died within minutes from a heart attack caused by Bupivacaine toxicity at Great Western Hospital (GWH), Swindon, where she had worked as a theatre nurse.

A jury of six women and three men at Trowbridge in Wiltshire took 17-and-a-half hours to return its unlawful killing verdict by a majority of seven to two. The jury foreman said: "Negligent storage of Bupivacaine caused the fatal administration."

No individuals were named in the wording of the verdict, which was: "Mayra Cabrera was unlawfully killed - gross negligence/manslaughter - storage and administration."

It is the first time an unlawful killing verdict has been found against an NHS corporation - rather than solely one individual within one, according to Rebecca Dennis, counsel for midwife Marie To. During the month-long inquest, Mrs To was alleged to have made the fatal blunder, and repeatedly forced to deny that she had mistakenly put up the 500ml bag of Bupivacaine.

Mrs To was on duty shortly after Mrs Cabrera gave birth to son Zac, who survived, at 8.14am on May 11 2004, the inquest heard. Following the error, she began to fit. At 10.27am she was certified dead.

Mrs Cabrera's husband Arnel, 38, said after the inquest: "The midwife's failure to accept responsibility or show any remorse for her actions has made me very bitter and angry. I cannot forgive her and now hope that the police and Crown Prosecution Service will prosecute her for manslaughter."

Detective Ian Saunders, of Wiltshire Police, said he would be submitting transcripts of evidence heard at the inquest to the Crown Prosecution Service for further consideration. A decision not to charge anyone was made by the CPS following an initial police inquiry into the death.

Lyn Hill-Tout, chief executive of the Swindon and Marlborough NHS Trust, which has always admitted liability for the death, said: "We sincerely hope that other hospitals and maternity units like ours will learn from the bitter lessons we have learnt."